The nurse is assessing a client's thyroid. The nurse determines the client's thyroid is non-palpable and non-tender. Which is the best explanation of these findings?
The client should be placed on levothyroxine
The client will need a removal of the thyroid gland
This is a normal finding
The nurse did not complete the assessment correctly
The Correct Answer is C
Choice A reason: Levothyroxine treats hypothyroidism, but a non-palpable, non-tender thyroid is normal, not indicating low hormone needing replacement, so this is unnecessary.
Choice B reason: Thyroidectomy addresses hyperthyroidism or masses, not a non-palpable, non-tender gland, which is physiologically normal, making surgery irrelevant here.
Choice C reason: A healthy thyroid is typically non-palpable and non-tender, indicating no enlargement or inflammation, aligning with normal anatomy, so this is correct.
Choice D reason: Proper assessment finds a non-palpable thyroid as normal; suggesting error assumes pathology without evidence, when findings match expected norms.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Semi-Fowler’s aids breathing but doesn’t optimize cerebral blood flow, critical in ischemic stroke to perfuse brain tissue, less urgent than perfusion.
Choice B reason: Trendelenburg lowers the head, risking increased intracranial pressure in stroke, not reducing hypertension effectively, contraindicated for cerebral ischemia.
Choice C reason: Flat positioning may increase intracranial pressure, worsening ischemia; elevation enhances perfusion, so keeping flat isn’t the priority intervention.
Choice D reason: Raising the head 30 degrees improves cerebral perfusion by balancing blood flow and reducing pressure, the priority to minimize ischemic damage.
Correct Answer is A
Explanation
Choice A reason: ESRD impairs fluid excretion, causing hypervolemia, leading to edema, crackles from pulmonary fluid, and hypertension from increased vascular volume, matching these symptoms.
Choice B reason: Hypovolemia, low fluid volume, causes hypotension and dry tissues, not swelling, crackles, or high blood pressure, which indicate excess fluid, not deficit.
Choice C reason: Hyperkalemia elevates potassium, causing arrhythmias or muscle issues, not directly linked to crackles, edema, or hypertension, which are fluid-related in ESRD.
Choice D reason: Hyponatremia, low sodium, may cause neurological symptoms, but crackles, edema, and hypertension point to fluid overload, not sodium imbalance primarily.
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